Surgical Methods for Congenital Repair Studied : Several procedures were investigated; Rastelli was the most common, although not the norm in France.


Major Finding: Rastelli outcomes among different groups, overall rates of freedom from reoperation, and event-free survival were found to be unsatisfactory, with event-free survival rates at 10 years that vary from 24% to 49%.

Data Source: A retrospective study of 146 patients who underwent surgery from 1980 to 2008 in eight European hospitals.

Disclosures: The authors reported no disclosures deemed relevant by the editors of the journal.

Optimal surgical management of patients with transposition of the great arteries, ventricular septal defect, and left ventricular outflow obstruction is still considered controversial.

Although the Rastelli operation is the most commonly performed procedure, the Réparation à l'Etage Ventriculaire procedure and the Metras modification yielded the best long-term results for both survival and event-free survival, according to a retrospective study of 146 patients who underwent surgery from 1980 to 2008 in eight European hospitals.

The multicenter study compared use and outcomes of several different surgical operations for transposition of the great arteries (TGA), ventricular septal defect (VSD), and left ventricular outflow tract obstruction (LVOTO).

A total of 141 patients had TGA, VSD, and LVOTO; 5 patients had the TGA type of double-outlet right ventricle (DORV) with LVOTO. Only those patients for whom the surgical method chosen was equivalent to those for TGA, VSD, and LVOTO were included in the study; all other DORV types were excluded, according to Dr. Mark Gerard Hazekamp of Leids Universitair Medisch Centrum, Leiden, the Netherlands, and his colleagues from various European universities on behalf of the European Congenital Heart Surgeons Association.

The surgical procedures investigated were the Rastelli procedure (82 patients), arterial (24) and atrial (5) switch operation with relief of LVOTO, Réparation à l'Etage Ventriculaire (REV) procedure (7), and Metras modification (24), as well as the Nikaidoh procedure (4).

The type of surgery used on these patients has traditionally been performed differently in different countries, according to the researchers, with the REV procedure and Metras modification mainly performed in France and the Rastelli procedure being the norm in most other countries.

The patients had a median age at operation of 21.5 months (range 0.2–165.1 months) and a median weight of 10 kg (range 2.0–41.0 kg). Pulmonary stenosis was found in 119 patients, while 27 had pulmonary atresia. LVOTO was solely valvar in 24% of the patients, only subvalvar in 37% of patients, and multilevel in 39%.

The location of the most important VSD was known in 143 patients, with outlet septum in 102, inlet septum in 14, trabecular septum in 3, and a combination of the three in 24 patients. The great majority of the 140 patients for whom data were available had great artery commitment of the biggest VSD: to the aorta in 60, the pulmonary artery in 32, and doubly committed to both in 19. Only 29 patients had noncommitment of one of the great arteries to the VSD.

Overall postoperative survival was 92% at 1 month, 88% at 1 year, 88% at 10 years, and 58% at 20 years. Events were followed as an outcome and were defined as death, reoperation, transcatheter intervention, or cardiac transplantation. The frequent necessity of reintervention (40.7% over the entire follow-up period) caused the overall event-free survival to be much lower, at 85% at 1 month, 80% at 1 year, 45% at 10 years, and 26% at 20 years (Euro. J. Cardiothorac. Surg. 2010;38:699-706).

There were 41 surgical reinterventions and 20 percutaneous procedures, with the most frequent cause of reoperation being RVOT obstruction, including conduit failure (25.0%), followed by LVOT obstruction (7.9%), residual VSD closure (7.1%), and pulmonary artery plasty (4.3%).

In multivariate analysis, age at the corrective surgery, year of the operation, and type of operation were significant predictors for reoperation and transcatheter intervention, in general, as well as for RVOT reoperation/intervention. The younger the patient at the time of operation, the higher the risk of later reoperation, according to the researchers, leading them to speculate that the more recently the surgery was performed, the less the probability that a patient would undergo reoperation.

Reoperation for RVOTO was observed to be most common in patients with a Rastelli operation, according to the authors.

“Although there are some differences between Rastelli outcomes among different groups, the all-over rates of freedom from reoperation and, especially, event-free survival, are not satisfactory with event-free survival rates at 10 years that vary from 24% to 49%,” the researchers said.

“The Rastelli procedure was a significant independent risk factor for re-operation, with the REV/Metras and the Nikaidoh having the lowest re-intervention rates,” they wrote. Although they pointed out that the number of Nikaidoh operations was low, the technique was recent, and it required considerable surgical experience, so further studies are needed to confirm the benefit seen.

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